There is now the presence of purulent discharge, and the evidence of clinical infxn.
Are the steps of body’s natural processes of tissue repair, but it also varies depending on factors such as the type of healing, wound location and sizes.
Base structural support to wound (it provides wound strength); to feed new tissues; provides surface for epithelization; to decrease the size of defect; resurfacing of wound, wound closure
Hemorrhage can be caused by blood clots, slipped suture, or erosion of a blood vessel,INTERNAL HEMORRHAGE- can be detected by, swelling and distention at the area of the wound; EXTERNAL BLEEDING-appear under the area or escapes from the dressing and pools under the patient.
Infxn-bullet or knife wounds, intestinal surgeries, because the colonizing organisms complete with the new cell for O2 and nutrition and because their by products can interfere with a healthy surface condition, the presence of contamination can impair wound healing and may lead to infxn.
Wound care 09
Skin: structure and function General Functions Each skin layer has its own unique function Epidermis = protection Dermis = nourishment of epidermis Hypodermis = Composed mostly of adipose tissue insulation
Classifying woundsA wound can be defined as:“A cut or break in the continuity of any tissue, caused by injury or operation”(Baillière’s 23rd Ed)
Wound Types andCharacteristics CLOSED Contusion ( Bruise) – Tissue injury without breaking of skin. CD: Purpule contusion 5x7 cm on left face Hematoma – Tissue injury that disrupts a blood vessels; pooling of blood under the unbroken skin CD: 2 in diameter hematoma on left face
Sprain – Wrenching or twisting of a joint with partial rupture of its ligaments; causes swelling CD: Swelling of right foot and round malleolus. No bruising notedOPEN Incision- Surgically made separation of tissues with clean, smooth edges CD: Approx. 3-in incision on R lower quadrant of abdomen; well approximated; clean and dry with sutures intact
Laceration – Traumatic separation oftissues with clean, smooth edges CD: 2 in jagged (pointy, uneven) laceration app 4 cm deep on L sole foot.Abrasion- Traumatic scraping away ofsurface layers of skin CD: Raw appearing abraded area 2 1/2 in diameter on lateral aspect of lower leg.
Puncture – Wound made by sharp, pointedobject through sin or mucous membranesand underlying tissue. CD: Small circular entry wound on R palm from sharp pointing nailPenetrating- Variable – size open woundthrough sin and underlying tissues madeby a bullet or metal or wood fragment; mayextend deeply into body CD: Jagged Deep wound 10 in posterior on L leg.
Avulsion – Tearing away of a structure ora part, such as a fingertip, accidentally orsurgically. CD: Avulsion of L leg from VA. Attach only by skin.Ulceration – Excavation of sin and/orunderlying tissue from injury or necrosis CD: Ulceration on L sole foot 4 cm x 5 x 2 cm deep. Yellow drainage present. Wound edges reddened.
Wounds can be classified according to their nature:•
2. According to depthSuperficial Involves only the epidermis Injury is usually the result of fiction, shearing (cut) or burn.Partial Thickness Involves the epidermis and the dermis Wounds heal more quicklyFull Thickness Involves the epidermis, dermis, fat, fascia and exposes bone In order to heal, all dead tissue must be removed so that granulation tissue can gradually fill in the defect.
TYPES OF WOUND DRAINAGE Serous -clean, watery Purulent - thick, yellow, green, tan or brown. Sanguineous - bright red, indicative of active bleeding. Serosanguineous -pale, red, watery mixture of serous and sanguineous.
Wound healingAll wounds heal following a a specificsequence of phases which may overlapThe process of wound healing depends onthe type of tissue which has been damagedand the nature of tissue disruptionThe phases are:Inflammatory phaseProliferative phaseRemodeling or maturation phase
PHASES OF WOUND HEALING1. INFLAMMATORY PHASE-starts immediately after injury and lasts 3-6 days or 4-6 days.2 major processes occur during this phase …HEMOSTATIC AND PHAGOCYTOSISHaemostatic- Tissue and capillaries are destroyed, plasma and blood leaks. Area blood vessels constrict, platelets aggregates and bleeding stops, scabs ( rough protective crust) forms, preventing entry of infectious organisms.
Inflammation Characterized by edema, erythema, pain, temperature- increase blood flow, to wound resulting localized redness and edema, attracts WBC and wound growth factors. WBC arrive-clear debris from wound.
injury Exposure of plasma to injured site Release of HistamineActivation of Hageman Factor Capillary Permeability Vasodilation Kinin Prostaglandin Edema Inc bld Flow Clotting Tumor Rubor Dolor ( Swelling) (Redness) ( Pain) Calor ( Heat)
2. PROLIFERATIVE PHASE-extends from day 3 to about day 21 post injury.Macrophages continue to clear the wound debris, Stimulates Fibroblast to synthesize collagen 9 main ingr. For tissue scaring)New capillary networks are formed.
3. REMODELLING OR MATURATION PHASE-final healing stage may continue for I year or more.Remodeling of scar tissue to provide wound strength.
TYPES OF WOUND HEALING FIRST INTENTION HEALING-partial thickness wounds.- a clean incision is made with primary closure, minimal scarring.-expected when the edges of clean surgical incisions are sutured together, tissue loss is minimal or absent if the wound is not contaminated with microorganism.-e.g.-abrasion or skin tear.
SECOND INTENTION HEALING-granulation -accompanies traumatic open wounds with tissues loss or wounds with a high microorganisms count.-go though a process involving scar tissue formation a heal slowly because of the volume of tissue needed to fill the defect. -e.g.-contaminated surgical wound, pressure ulcer.Delayed primary healingIf there is high infection risk – patient is given antibioticsand closure is delayed for a few days e.g. bites
Wound can result from:Planned events – Such as surgeryAccidents – such as a fall from a bikeExposure to environment – such as thedamage to UV rays in sunlight.
Clinical appearanceDescribes the type of material presentIn the base of the wound: Slough (yellow) Necrotic tissue (black) Infected tissue (green) Granulating tissue (red) Epithelializing (pink)
Sloughy wound • Aim: to liquefy slough and aid its removal • Dead cells accumulated in exudate • Prepare wound bed for granulation • Assess wound depth and exudate levels • Hydrogels, hydrocolloids, alginates and hydrofibre dressings
Necrotic wound • Aims: to debride and remove eschar Provide the right environment for autolysis • Assess wound depth and exudate levels • Hydrogels, hydrocolloid dressings
Infected wound • Aims: reduce exudate, odour and promote healing Clinical signs of infection Swab wound – systemic antibiotics Treat symptomatically: exudate and odour control Change dressings daily
Granulating wound • Aims: support granulation, protect new tissue, keep moist Assess depth and exudate levels Moist wound surface – non-adherent dressing Treat over-granulation Hydrocolloids, foams, alginates
Epithelialising wound• Aims: to provide suitable conditions for re-surfacing , films, hydrocolloids Disturb as little as possible
COMPLICATIONS OF WOUND HEALING 1. HEMORRRHAGE-risk of hemorrhage is greatest during the ist 48 hours after surgery.-emergency -N@- should apply pressure dressing to the wound and monitor vital signs. 2. INFECTION-surgical infection is apparently 2-11 days post operatively.
N@- watched for presence of changed in wound color, pain or drainage-culturing of the wound. 3. DEHISCENCE WITH POSSIBLE EVISCERATION-may occur 4-5 days postoperatively.-involves an abdominal wound in which the layers below the skin separates.N@- an increase in flow of serosanguinous drainage into the dressing can indicate
impending dehiscence.- If occurs N@ should be quickly supported by sterile dressing soaked in sterile normal saline. -position? Client in bed with knees bent… why? To decrease pull on the incision. and? Notify physician……
WOUND MANAGEMENT 1. DRESSINGS - material applied to wound with or without medication, to give protection and assist in healing. -what are the purposes?To protect the wound from mechanical injurySplint or immobilized the wound.Absorbs dressingPrevent contamination from bloody discharges
Promote homeostasis, (pressure dressing) Debride the wound to kill or inhibit microorganism provide a physiologic environment conducive to healing provide mental and physical comfort for the patient.
What are the types of dressings?a. DRY TO DRY DRESSINGS-used primarily for wounds closing by primary intention.-offers good protection, absorption & provide pressure-they adhere to the wound surface when drainage dries. - when remove can cause pain and disruption of granulation tissue.
b. WET TO DRY DRESSINGS-used for untidy or infected wounds that must be debrided and closed by secondary intention.>how can it be done?-gauze saturated with sterile saline or antimicrobial sol’n. is packed into the wound, the wet dressing are then covered by dry dressings>when to changed?-when it becomes dry
c. WET TO WET DRESSINGS-used on clean open wounds or on granulating surfaces.-provide a more physiologic environment (warmth moisture) which can enhance the local healing processes and assure greater patient comfort.-surrounding tissues can become ulcerated. high risk for infection.
2. DRAINS- device or a tube used to draw fluids from an internal body cavity to the surface.-what are the purposes?a)placed in the wounds only when abdominal fluid collections are present.b)placed near the incision site> wound drainage-drains placed within the wounds are attached to a portable suction with a collection container.e.g. hemovac, jackson-pratt, penrose drain.
3. BINDERS AND BANDAGES -what are the purposes?Creates pressure over the body partsImmobilize body partsReduce or prevent edemaSecure a splintsSecure dressing
Dressing choiceWhat is available?How do we choose?Does the patient have a say?Do we consider cost?Are choices restricted by a protocol?How do we evaluate?
Dressing A process of cleansing the wound using aseptic solution.∆ To aid debridement The ideal dressing∆ To remove excess • A dressing that exudate creates the optimum∆ To control bleeding environment∆ To protect a wound • Wound debridement∆ To support healing • Wound cleansing • Alternative therapies
TYPES OF DRESSINGS Hydrogel Dressings Hydrogels are indicated for management of pressure ulcers, skin tears, surgical wounds, and burns, including radiation therapy burns. Because they contain up to 95% water, hydrogels cannot absorb much exudate and should be reserved for dry wounds or wounds with minimal to moderate drainage.
Hydrocolloid Dressings Because they are occlusive, hydrocolloid dressings do not allow water, oxygen, or bacteria into the wound. This may help facilitate angiogenesis and granulation. Hydrocolloids also cause the pH of the wound surface to drop; the acidic environment can inhibit bacteria growth. Like hydrogels, hydrocolloids can help a clean wound to granulate or epithelialize and encourage autolytic ( distruction of cells by own enzymes) debridement in wounds with necrotic tissue. However, because of their occlusive nature, hydrocolloids cannot be used if the wound or surrounding skin is infected.
Alginate DressingsPrevious columns have addressed products that areappropriate for dry wound beds or wounds with minimalexudate or drainage-namely, hydrogels andhydrocolloids. In contrast, alginate dressings absorbmoderate to high amounts of wound drainage.In wounds with moderate to heavy drainage, the alginateforms a gel when it comes in contact with wound fluid.Capable of absorbing up to 20 times its weight in fluid, analginate can be used in infected and noninfected wounds.Because an alginate is highly absorbent, it should not beused with dry wounds or wounds with minimal drainage; itcould dehydrate the wound, delaying healing.
Composite dressings Made of three layers. The layers of the composite dressings combine to form an antimicrobial barrier for moderate to heavy exuding wounds. Some composite dressings also gradually release silver over time to promote healing. Our selection of silver dressings include the popular Acticoat, Aquacel and Aquacel AG. Composite dressings have multiple layers and can be used as primary or secondary dressings. They are appropriate for wounds with minimal to heavy exudate, healthy granulation tissue, necrotic tissue (slough or moist eschar), or a mixture of granulation and necrotic tissue Use composite dressings cautiously if the patient is dehydrated or has fragile skin. Keep in mind that some insurers will not reimburse a facility or provider if a composite dressing is used as a secondary dressing with a hydrogel or impregnated gauze.
Transparent Films Film dressings are flexible sheets of transparent polyurethane coated with an acrylic adhesive. They can be used as a primary or secondary dressing. These dressings are semipermeable, vary in size and thickness, and have an adhesive that holds the dressing on the skin. They conform easily to the patients body but do not hold well in high-friction areas, such as the sacrum or buttocks. Because films are transparent, the wound can be easily monitored. Because films are semiocclusive and trap moisture, they allow autolytic debridement of necrotic wounds and create a moist healing environment for granulating wounds.
Principles Explain the procedure to the patient Handwashing before and after the procedure Clean from least contaminated to the most contaminated area Use separate cotton for each stroke Start from the center going outward• Observe aseptic technique
Procedures1. Check physicians order for specific wound care and medication instructions. Helps to plan for proper type and amount of supplies needed.
Procedures2. Secure equipment and wash hands thoroughly. To save time and effort. Reduces transmission of pathogen
Procedure3. Assess the existing dressing Indicates types of dressing or applications to use.
Procedure4. Explain the procedure to the patient and instruct client not to touch wound area or sterile supplies. Decreases anxiety and to gain cooperation. Sudden unexpected movement on clients part could result in contamination of wound and supplies.
Procedure5. Loosen and remove the dressing with the use of the dressing forcep. If the dressing adheres to the wound, loosen it by moistening with sterile NSS. Microorganism can be transferred by direct contact from dressing to hands. An intact scab is a body defense and can be damage if not handled gently.
Procedure6. Observe the dressing for the amount type, color and odor of the drainage. Provides estimate of drainage amount and assessment of wounds condition.
Procedure7. Discard the soiled dressing in the waste receptacle. Reduces the transmission of microorganism.
Procedure8. Clean the wound aseptically using the dressing forcep from the center going outward in circular motion with;A.Betadine cleanserB.Dry gauzeC.Betadine antiseptic solution(use each gauze for only one stroke)
ProcedurePrevents contamination of previously cleaned.Prevents introduction of organism into wound.Reduces excess moisture, which couldeventually harbor microorganism.Helps reduce growth of microorganism
Procedure9. Apply a new dressing by gently placing the gauze sponges at the wound center and moving progressively outward to the edges of the wound site. Promotes proper absorption of drainage and protects wound from entrance of microorganism.
Procedure10. Secure the edges of the dressing to the patient’s skin with strips of adhesive tapes. Ensures that dressing remains intact and covers wound.
Procedure 11. Make the patient feel comfortable and tidy the unit.Promotes clients sense of well-being. Enhances comfort.
Procedure12. Do the aftercare of the equipment. Soak the dressing forceps in 5% lysol solution for 30 minutes, then wash them with soap and water. Rinse them then dry. Send them to the CSR for sterilization..
Procedure13. Wash hands. Prevent spread of microorganism.
Procedure14. Chart: site of wound, character of wound/ discharges, treatment given if any(e.g. ointment used) and reaction of patient. For proper documentation and legal purposes
ReferenceFundamentals of Nursing, fifth edition, page1598-1605 by Potter and Perryhttp://images.google.com.ph/imgres?imgFundamentals of Nursing, seventh edition,page636-645 by WolffFundamentals of Nursing by Kozier